“Improving outcomes by working together”

That’s one reason why the joint Kings Fund/Nuffield Trust recommendations to the Future Forum and the DH on integrated commissioning are worth your attention.  Have they found the answer? Is this the map to the Holy Grail?  Much as we would like to be believers, we remain doubters. There is much more to “improving outcomes” than simply “working together”.   Here’s why.

Only a few pages into the report it is quickly apparent that merger and even institutional integration between health and social care is not on the agenda – not this one anyway. What they are talking about is integration of services around the needs of individuals (elderly people, children) with complex needs and many others with long term needs, including end of life care. That is all to the good but not new.  It should have happened a long time ago of course.  There is already a guide to this, the National Voices Principles of Integrated Care which the latest report endorses – and rightly so.

Social care elephant in the room 

There is a big policy elephant in the room: the vexed social care resourcing issue.  The report merely identifies this as a “barrier” to integration.  That it certainly is and the explosion it is going to cause  this spring when we finally have to bite the bullet on how to fund social care will rock the political foundations.  But  by far the biggest barrier to integration is the acute-focused clinical culture of most of the NHS and the local authority protectiveness of much of social care. These are like oil and water and, frankly, they need nuking.  Our view is that without organisational integration, common pots of money and buckets of inspirational and innovative leadership in the professions and councils, the “pace and scale” of change which the report says is vital is unlikely to happen. There are too many vested interests conspiring against it.

Patient and carer power?

Could patients and carers not rise up, charge the barricades and demand integrated services?  We’d like to see it happen.  Individual budgets may be one way to tunnel underneath the obstructions.  But it is not sufficient to talk, as the report does warmly, about personal health budgets. That is only part of the picture: we need integrated health AND care budgets for individuals – at realistic levels – as anyone with a long term condition will tell you who uses services across the sectors.

Patients and carers could leverage more power in the system in their role as budget holders.  But they need brokers and guides to act as agents and facilitators with service providers if they are to maximise their purchasing power and not to get ripped off.  Here is a big opportunity for 3rd sector bodies and for specialist clinicians like neurological nurses  - will they rise to it? We’d like to see that, especially now that there are strong signs that the NHS pension scheme will be extended to non-NHS providers.

More radical thinking needed 

The report is a prompt to address the cultural and institutional blockages stopping integration.  It is not just about resources. It is about more subtle things, including professional leadership and personal fulfilment. Peter Carter made this plain before the Health Committee last month: the impulse of good practice like integrated services has to be “encrypted into the culture”. Florence Nightingale might have said it differently, but not any better.

Until we develop more capacity in primary and community health care to deal with demand outside of hospitals, too many elderly, frail people and others with complex and long term conditions of all ages are going to end up there by default as the NAO report on neurological services shows.  This is bad for them and bad for the institutions that have to receive them.

The reality of NHS provision – and it does not have to be bricks and mortar, there can be “virtual wards” in the community – has not matched the political rhetoric about this goal. All governments share the blame here and a few glib targets will not turn the situation around quickly. Just look at who is occupying a high proportion of acute beds to see what the problem is when people cannot be cared for at home or in intermediate settings which are better and safer for them. Better yet, we need to prevent a much higher proportion of unplanned admissions in the first place.

Health and care are a continuum. We must break down the funding and cultural barriers between the health and care sectors and the rivalries and turf wars between professions. To achieve integrated services, professionals must do this in in partnership with patient leaders.

At bottom the Kings Fund/Nuffield report is well intentioned but simply does not go far enough with radical thinking.   The owners of the services – that means the public who pay for it and the people who use it – should demand nothing less.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

Is Surrey sure about Assura?

Why is that? The change of tune is because NHS Surrey decided on 16^th September  “that following a rigorous evaluation process Assura Medical Limited is the preferred  bidder for the services currently provided by Surrey Community Health.”  Assura will take on services in North West and South West Surrey, as well as some delivered Surrey-wide, including sexual health services and prison healthcare.

Those words could set off squawking  in the NHS human resources henhouse as well as in the wider public sector procurement world. What the Surrey population thinks about it, no one knows. Surrey LINks were said to be “fully involved throughout the process”.  We do not think that is sufficient involvement when the contract is worth at least £450m and the services are so fundamental to the well-being of the Surrey public.

There should be active citizens involved in all stages of the procurement process for something of this magnitude.  On a local health centre procurement I am involved with at the moment, there is also a very able representative of the patient participation group at the practice being tendered. It makes a difference.

Up until now, Assura Medical has been mainly a health care property developing organisation, 75% owned by Virgin Group since 2010.  They design and build primary care centres and community hospitals.  That’s all fine, but are they the right kind of business to start providing community health services themselves?  This is not elective surgery after all, but long term, usually complex stuff – “messy” as one of my community nursing friends described it.  And you can’t “cherry pick” it.

Probity, accountability, not to mention conflict of interest?

It’s surprising to a lot of people I talk to that a company like Assura is interested in a major community service provider business. After all, they only disposed of their pharmacy business in June this year in order to focus on the property development side.  But if they can add value within budget and achieve quality outcomes – including user/carer satisfaction of course – perhaps we are about to be surprised?   The local social enterprise providers in Surrey might be surprised as well, but that’s another story yet to be written.

It will be interesting to see how the new Assura business model works and is able to avoid conflicts of interests with local GPs.  Assura’s usual operating model is to provide primary care services via partnerships with local doctors in “GP provider companies”, of which it currently has 25 across the country. Each provider company is half owned by the local GPs, with the remaining half owned by Assura.   And who is it that makes referrals to community health services?  Oh yes, it’s local GPs.

A lean time for mutuals in “Open Public Services”? 

The “Open Public Services” white paper approach could have a sting in the tail for social enterprises, mutuals in particular, if the Surrey decision sets a precedent.

The last word -for the moment –  should go to Peter Holbrook, Chief Executive of Social Enterprise UK, quoted in the Financial Times about the decision:

“If Central Surrey Health, the government’s flagship mutual social enterprise, which has demonstrated considerable success in transforming health services and increasing productivity can’t win, what does this say for the future of the mutuals agenda? Central Surrey Health reinvests all the profits it makes locally. It is difficult to imagine how Assura, with shareholders expecting a financial return, could do more to benefit people in Surrey.”

Meanwhile back in Surrey

While all this is going on, over in East Surrey a new “right to request” social enterprise ”First Community Health and Care” – a CIC (Community Interest Company) –  is “going live” on 1st October.  What must the former PCT community staff leading this be thinking now that Assura is moving in as the new big boy on the Surrey community health block?

Clearly our neighbour to the South is somewhere to keep an eye on for signs of what the future of community health and care businesses might look like.  Maybe a future blog post will have the title “It’s an Assura Thing – Mutuals Defeated in The Battle of Surrey 2011″.  Time will tell.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

Our concern  is that with the momentum leading to shut down of Primary Care Trusts, the needs of people with long term neurological conditions (LTNC) would get lost – not because they are few in number, because their conditions were clinically complex and often not familiar to GPs. For example, the average GP may only see 1 or 2 people with motor neurone disease in a lifetime  of practice.

With the creation of hundreds of new consortia, the danger is that the new web-based commissioning tools which MAC assisted Neurological Commissioning Support (NCS) to create would not get used and the lives of people with LTNC would deteriorate because of inadequate and uncoordinated services in health and social care.

Mr Lansley said he understood this issue.  He told Radio 4′s PM  audience that improving health outcomes for patients with complex needs was a priority in the new Health and Social Care Bill and would be delivered through the duty on the NHS and Local Authorities to work closely together and to integrate services.  He gave end of life care and palliative care as specific examples.

Mr Lansley has visited the MND care centre in Cambridge and spoken to people with MND about their needs. Full marks for that.  He said that PCT-level commissioning of services for MND had not worked very well to deliver improvements in quality.   His view was that if the new GP-led commissioning consortia were sufficiently large – he understood that the prevalence of MND was about 7 per 100,000, so he was well briefed –  then they might commission for this group or – more likely – they could form a broader network for that purpose.  So collaboration in commissioning is the answer.

We already have cancer networks, but neurological networks are thin on the ground.  This is the opportunity to expand them.   He stressed that the new arrangements would encourage collaborative commissioning for complex and rarer conditions.

This is also an opportunity for the neurological 3rd sector bodies to step forward.  Mr Lansley, as he has previously, again singled out the Neurological Commissioning Support service – a joint initiative of the MND Association, Parkinson’s UK and the Multiple Sclerosis Society – and a former MAC client – for praise.

Publicity like that can’t be bought and we hope our friends in the LTNC community can use this as powerful leverage with the new commissioners. We wish them well.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

Is it nudge or fudge? Your verdict on Andrew Lansley’s public health white paper Healthy Lives, Healthy People: our strategy for public health in England launched in Wandsworth on Tuesday, ultimately depends on your philosophical stance about what’s desirable  – and possible – when it comes to improving the health and the health-related behaviours of individuals and groups.  But one thing is certain, Mr Lansley’s proposals cast the net wide, draw in issues of undeniable importance and deserve a good hearing.

Driving over the cliff is not attractive

As a health promotion specialist, I am prepared to take the white paper at face value.  After all, if this approach does not succeed in helping to stem the tide of (mainly) lifestyle related health deficits and widening health inequalities, then we are rapidly approaching a tipping point of unaffordable demands on our healthcare system and everything related to it regardless of who the commissioners are. If we go over a cliff, it matters little if GPs, PCTs, Local Authorities or Uncle Tom Cobley are in the driving seat. Public health failure means we pass the point of no return.

At the weekend, Andrew Marr wondered “how will this government persuade us to drink less, stop smoking and eat our greens – and actually why should  they?” In reply, Mr Lansley said his proposals spread across government and indeed beyond government “to ensure we really impact on the determinants of health.” Why?  Because, he continued, “many of the poorest need the greatest support; health inequalities are too wide, we need to deliver improvements in lives of the poorest fastest.”

That is the right vision if we are going to address health issues which have their genesis in employment, housing, environment and education but which present to an NHS which can do little to address their causes.  As Mr Lansley told Andrew Marr:  “It comes down to responsibility; we need to support people to be responsible.”

Radical shift promised – is it deliverable?

Healthy Lives, Healthy People promises “a radical shift in the way we tackle public health challenges.”  Does it deliver a policy of that magnitude? At 100 pages, 107 footnotes, and partnered with a 64 page evidence review – a publication in its own right Our Health and Wellbeing Today with 227 references  – this is a heavyweight effort.  And don’t forget an impact assessment of 156 pages.

And this isn’t the end of the policy train either.  The white paper promises a flood of related documents next year covering health visitors, mental health,  tobacco control, the public health “responsibility deal” with industry, obesity, physical activity, social marketing, sexual health, teenage pregnancy, and pandemic flu – not forgetting health protection, emergency preparedness and response.  Whew.

Mr Lansley’s introduction makes his approach clear.  His biggest concerns are the predisposing factors and consequences of obesity, sexually transmitted infections, drug and alcohol use, and smoking. But nannying and diktat are out. Instead this will be a new approach “that empowers individuals to make healthy choices and gives communities the tools to address their own, particular needs.”   Local government will have the “freedom, responsibility and funding” to innovate and improve local public health and local people will be the judge of their efforts.

Moving Marmot forward

The white paper strategy takes as its point of departure Michael Marmot’s seminal review of health inequalities in England, Fair Society, Healthy Lives (February 2010) with its emphasis on early years development and education.  

The big issue will be resources of course – money and people.  Mr Lansley says public health money (likely to be around a modest £4bn of the £100bn+ the NHS spends annually) will be ringfenced within the NHS. The new Public Health England service based in local authorities and led by Directors of Public Health will be the shock troops against health inequalities working in partnership with public, private and third sector bodies. And there will be a “health premium” incentive to reward efforts to improve good outcomes that address health inequalities  It is to be a grand coalition to improve local health, but one can already hear town hall voices saying the cash won’t be enough and it should be theirs anyway. Perhaps they have a point; only time will tell.

Fine words are one thing, legislation is another and we shall now have to wait until early 2011 for the long promised Health and Social Care Bill which will bring all of this into reality (including the switch on of Public Health England from 2012).  In the meantime, I urge you to read Mr Lansley’s White Paper and reflect on the challenges and opportunities it creates. These initiatives depending as they do on people making personal commitments to change are a challenge to a public sector more comfortable with redesigning structures and managing inputs and process and commissioning services than it is with delivering outcomes that add value. This new commitment to delivery is impossible without the consent and commitment of the public.

Perhaps the final words – at this stage at least – should be Professor Marmot’s welcoming Mr Lansley’s white paper:

“I am particularly pleased to see the clear recognition that health is determined by wider social influences, and that these have an effect throughout our lives – right from the start. It clearly makes the abolition of child poverty, early years development and education, good working conditions, healthy and sustainable communities, and good conditions for older people a centre part of a strategy for reducing health inequalities. ‘Nudges’ will, however, only encourage individuals to exercise responsibility for their actions if they are combined with wider social programmes, regulation and a focus on equity from the outset.’

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.

It was a bit of a technical pile-up really.  The screen displayed loads of questions in rapid fire order (I counted over 120 over 60 minutes). Lansley’s answers were slotted in seemingly at random. People watching on screen found it hard to keep up with the rapid flow and link up the Q with the A.  Note to DH IT boffins – Next time it would be better to have a live presentation and see Lansley answering questions sent in by viewers.

That aside, Mr L. didn’t really say anything we had not heard or read before. There were lots of things not “on topic” from questioners, including a determined assault from well organised ME suffers about the failure of GPs to take them seriously because NICE guidelines don’t identify a physiological cause for their condition.  I felt positively sorry for Lansley at some points.   All the content will remain on site here

DH has promised to supply answers to everything, which is noble of them when facing  questions like:

“How are patients expected to make informed choice of medicines when even doctors can find the data confusing? ”  and

“Choice is good but not at the cost of commercialisation of the NHS. The proposed reforms seem to promote a consumerist approach to healthcare which isn’t conducive to the Doctor-Patient relationship. Can the Hon’ble Secretary of State reassure GPs that there will be level playing fields if they are to compete against conglomerate giants who will cherry-pick services they offer to the public?”

There was predictably lots of cynicism about the waste of £bns on IT systems in the NHS already and wondering why the proposed “information revolution” would be any better?   Lansley insisted it was about empowering patients and clinicians with information close to where patient decisions were made (“shared” of course) and it was about achieving better outcomes (effective, safe, value for money etc).  He was unshakable on this.

Inevitably this discussion of information and what to do with it got shunted into the debate that never resolves about  “choice”  - whether people wanted it, who should enable choices, what about people who were digitally isolated, and conflicts of interest if GPs had tie ups with private providers and did not give “impartial” information.   As if there was any such thing as truly “impartial” information.  Some people did mention the report in today’s media that NHS Choices health information portal was getting 100m hits a year (up 10% on 2009) and “saving” some £44m a year by diverting people from attending GP surgeries.  That’s what Lansley wants to see more of.

Mr Lansley did say one thing on combined patient-held budgets for health and social care that was a step forward.  He wants to give people with long term conditions the money (national tariff one assumes)  and let them divide it themselves.  MAC has argued for this for a long time, particularly for people with long term neurological conditions.

I have said social care users should exercise more control including access to personal budgets. Once their need has been assessed, it is very predictable. This isn’t the case for health care. The scope is limited as the cost varies a great deal. But we are going to look at cases of long term conditions. The most effective way of breaking down the barriers between health and social care will be to give a combined budget and let people to divide it themselves.

Micro budget holders will need information to help them be good commissioners and consumers, that’s for sure.  And there are bound to be plenty of people getting into “brokerage” for just this reason.  It could be one of the government’s job creation schemes led by the 3^rd sector.

This is a good reason for the charities backing the Neurological Commissioning Support (NCS) project to push on with making the Neuronavigator tool accessible and usable for individuals with the neurological conditions covered in it.

Of course, big bits of paper are all very well, but not everyone has that much wall-space so it seemed entirely logical to turn it into an interactive web-based tool.   This time the tool includes not only a Year of Care for MND but also for Multiple Sclerosis and Parkinson’s Disease and has been produced with the support of the three big charities (MNDA, Parkinson’s UK and the MS Society).

Commissioning Ready Reckoner

Using demographic data and recognised reference costs, and supported by a raft of evidence and good practice guidance, it takes the form of a ready reckoner enabling commissioners to calculate the costs of providing the best possible care for people living with these particular neurological conditions.  At the moment it is aimed at PCT and GP consortia based commissioners but in future NCS hopes it will be possible to use it to develop costed personalised pathways for individuals.

We were very pleased to be involved in choosing contractors and setting the goals for the development of this tool and it is great to see that our chosen developer Ben Eveling of Beetlebrow has succeeded in turning our big “ordnance survey map” into an easy-to-use “app” which, let’s hope, will be the first of many more to help commissioners get to grips with commissioning for individuals with complex needs across health and social care.  It is a good sign, we hope, that Mr Lansley has said he likes this approach.

Commissioners All At Sea?

Commissioning is in flux in England as our NHS is “liberated” whether it wants to be or not.  We would be the first to acknowledge that no matter how smart the kit is, it will not be much use unless the new commissioners understand what they are doing and what a year of care pathway tool is for in terms of value for money, improved patient and carer experience and improved quality outcomes.  As our favourite management consultant Florence Nightingale was fond of saying “no report is self executive”.  She meant it had to be sold in, to use the parlance of marketing.  That is also true of tools for new commissioners.  This is a leadership challenge for the neurological organisations leading NCS.  We highlighted some signs during the summer when the NHS Operating Framework was changed that could spell difficulties in keeping the commissioners’ eyes on the neurological targets.  And that was long before the present distractions of an austerity financial regime which will not spare the NHS.

Setting a Clear Course

To address all of this, we need leadership from neurological leaders based on setting a clear course for commissioning at consortium level and and the role of the National Commissioning Board in terms of the division of long term neurological conditions between them.  Some will be “specialised” and some won’t be – and should not be. Some will have “specialised” elements in their intervention possibilities and then there is always the question of new drugs appearing on the market to consider.  Cancer drugs are getting all the running about this, but there are plenty of other conditions to consider in terms of NICE approvals and their cost benefits.

Safe Haven Needed for Neurological Commissioning

We think all of this this is going to be troublesome because there is no consensus about what goes where for neurological commissioning.  GPs historically do not have a strong affinity with neurological conditions and there will be temptations to let this drop off the commissioning table.   What proactive line is the neuro 3rd sector community going to take to overcome this?  And what are they doing to own “Nothing about me without me” for people with LTNC and switch on the power of the patient and carer voice?

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive health, care and education organisations.

We assist with the development of e-applications and websites to engage users and support commissioners.

In getting ready for this, I had gone through the suite of consultation documents again but lost count after 100 questions, many of which were too detailed and repetitive anyway.  So I opted to boil the main points from Commissioning for Patients and Increasing Democratic Legitimacy down to to two sides of A4 and focus on what I think are seven questions that address the meat of the consultation from the patient and public perspective.  You can read these below together with my precis of what the participants in the group had to say.

Two themes stand out

Two themes during the discussion really stood out for me.

First, the overriding importance of real patient and public involvement in new arrangements – “No decision about me without me” is a hostage to fortune and the Government will be mercilessly pilloried if they abandon it or, worse, let the special interests water this down to mere lip service or box ticking.

Second, the central role of local authorities in leading on the things that matter to local people about health and well-being.

The question came up unprompted several times about why commissioning was to be divided between GP consortia and Councils.  Would it not be more effective, people asked, to deal with Wandsworth as a single place with a single population and a common pot of resources and expert people working in a single agency to do the work across health and care?

What people said

Here are the questions we used and a summary of what the participants had to say about each one.

How can GP consortia and the NHS Commissioning Board best involve patients in improving the quality of health services?

Involvement and whatever else is needed to improve the quality of health services through engagement of patients and carers should be contractual and enforceable.

Lay people who are  members of decision making bodies – commissioning consortia, health and wellbeing boards etc – must be paid an appropriate attendance allowance in recognition of their time and the shared accountability they are taking on.

How can GP consortia can work closely with secondary care, community partners, local authorities, and other health and care professionals to design joined-up services that are responsive to patients and the public?

Pathways reflecting patient journeys must be commissioned.  Third Sector bodies must be helped to be able to deliver a share of public services if they have the right skills.

Local authorities should take the lead for long term conditions and services for older adults, children and learning disabilities.  Possibly also for mental health.

How can GP consortia be patients’ advocates and accountable to patients and the community for their decisions in some meaningful way?

Consortia must have boards with lay people (lay members) recruited and paid to be on them.  There should also be lots of opportunities for patient representatives to influence what the consortia do. This should be in the consortia’s contract with the National Commissioning Board. Perhaps lay people should be elected to the boards?

Local Authorities should have strong scrutiny powers to see that consortia are involving patients and carers and making themselves accountable to the community.

Consortia should focus on achieving outcomes that improve the patient experience and reduce inequalities as well as making better use of less resources.

Local Healthwatch and the Care Quality Commission should have powers to inspect what consortia are doing.  If consortia fail or do not involve their communities, they should be closed down and their responsibilities taken over by a successful consortium.

Are statutory H+WBBs led by Councils a good idea?

Yes, but there must not be struggles for power and resources between Councils and the GP consortia.

Should local HealthWatch take on new functions around health complaints advocacy and patient choices? If so, what needs to happen to achieve that and support people who do not have the means or capacity to make choices about their care?

Local Healthwatch should not get involved with health complaints or advocacy as this is a specialised area which the local authorities should lead on.  But Local Healthwatch should be involved with providing information and helping people to make good choices.

There should be a close working relationship between the local authority and Local Healthwatch.

How should patient groups in practices relate to local HealthWatch, to local authority Health and WellBeing Boards and to GP commissioning consortia?

Patient groups in practices should be able to and encouraged to join Local Healthwatch but not required to join it.  They should be part of the wider reference and intelligence networks of the HWBBs and commissioning consortia.  There should be a duty to involve patients and the public including patient groups.

How can the user, carer and public voice across health and social care be strong and most effective?

Patient participation groups in GP practices are the bedrock for achieving strong and effective user and carer voices across health and social care. If they existed in all practices, it would give the biggest outreach possible into the community.

Head stands

SRPs are designed, in the word’s of the DH one,  to turn government on its head, taking power away from Whitehall and putting it into the hands of people and communities. Once these reforms are in place, people themselves will have the power to improve our country and our public services, through the mechanisms of local democratic accountability, competition, choice, and social action.

This will be a neat trick in more than one sense of the word if it can be achieved.  We hope it can, because the first priority in particular strikes a strong chord with us about user participation and control of public services.

New priorities

1. A patient-led NHS –  Strengthen the patient’s ability to exercise extended choice, to manage their care and to have their voice heard within the NHS

2. Shift resources to promote better healthcare outcomes – Shift focus and resources towards better healthcare outcomes, including national healthcare outcome measures, patient-reported outcomes and patient experience measures

3. Revolutionise NHS accountability – Create a long-term sustainable framework of institutions with greater autonomy for doctors and nurses, and greater accountability to patients and the public, focused on outcomes

4. Promote better public health – Promote better public health for the nation by centring the Department’s focus on public health, developing a clear strategy and partnering with the voluntary and private sectors

5. Reform social care – Enable people needing care to be treated with dignity and respect; reform the system of social care to provide much more control to individuals and their carers, easing the cost burden that they and their families face

Two observations

First, why have we had to wait so long for something like this? These are the obvious things for a government department responsible for health, well being (public health) and social care to be doing in the first place! Let us hope there are enough talented and committed people left when the department is slimmed down to achieve them.

And an elephant warning

Second,  priority 5 about reforming (adult) social care will turn out to be the hardest to achieve. It is the elephant in just about every room you care to enter.  There is no consensus on form or funding.  That was amply demonstrated by the pre-election squabbles about funding processes and affordability.

The Coalition Government has promised a commission on social care to look at all the options. We know what these are likely to be of course.

There should be a government “vision for social care” by the end of this year, with a white paper in 2011.  The Social Care Commission, when established, will report within 12 months on social care funding options.  The White Paper states: The Commission will consider a range of ideas, including both a voluntary insurance scheme and a partnership scheme. As a key component of a lasting settlement for the social care system, we will reform and consolidate the law underpinning adult social care, working with the Law Commission.

We wish this well.  But if you thought GP commissioning was going to be a punch-up, just wait until we really get into social care funding and provision for a burgeoning older population and the many more people with disabilities who are living for much l0nger.

That will really be the main event.  Tickets available from the usual outlets very soon.  Book early for a ringside seat.

Liberating the NHS

Shaping the new order

Speaking in the Commons this afternoon as the document was published, Secretary of State for Health Andrew Lansley said his objectives were putting patients right at the heart of their care, putting clinicians at the heart of decisions about services and achieving health outcomes comparable of our neighbours.

We are to have an outcomes framework identifying what the health service should achieve and it will be up to the professionals (in collaboration with the public and patients if Lansley is serious about “no decision about me without me”) to say how it should be achieved in each part of the country.

Some of the other highlights of the new order include:

• A payments system that acts as a driver for quality, safety and integrated care not just a reward for activity (very welcome)
• Decision making as close to patients a possible, including patients with long term conditions having budgets (we hope for health AND social care combined) to make real choices about their care.
• Real, local accountability: Local Authorities will agree local strategies to integrate NHS, public health and social care together.  (fine, assuming councillors rise to the challenge and there isn’t likely to be extra money for cash-strapped authorities)
• Consortia will commission NHS services in line with the local health plan agreed with the local Council; this is how GPs will lead bottom up redesign of services:“GPs are senior professionals in public service and paid well for that.” No opting out.
• Patient choice over treatment options, including the consultant-led team that treats them, based on a torrent of information to guide informed choices
• Choice of GP practice and  power to control our own patient records. (no practice boundaries)
• Patient voices will be heard and acted upon by Healthwatch as a national body working through local healthwatch incorporating the current LINks (across health and social care which is essential)
• An English NHS “liberated from command and control”, including all NHS Trusts to be Foundation Trusts with power in the hands of their employees and users: “Our ambition is to create the largest and most vibrant social enterprise sector in the world.” (could help with getting assets off the government’s balance sheet and sort the pensions issue too)
• Any willing provider in the health care marketplace, provided they deliver to NHS standards and prices
• A more powerful Monitor as economic regulator and CQC as the guardian of safety and quality standards
• The NHS Commissioning Board holding the national GP contract, managing performance, allocating resources to commissioning consortia and leading specialised commissioning (big job all of that, any applicants on the horizon?)

Liberation is a double edged sword

MAC’s initial reaction to all of this – our deeper thoughts are for later –  is that what Mr Lansley is proposing  - and the devil will be in the detail of the coming consultations and the autumn Health Bill – could certainly be “liberating” both in an innovative but also in a chaotic sense (think Pandora’s box)  - and probably at the same time.  The phrase “constructive discomfort” comes to mind.

But there’s a catch. The NHS in England must save recurrently some £20bn by 2014 - “every penny saved will be a penny reinvested for the benefit of patient care” Mr Lansley said. That takes many steady eyes and hands on the job and some well placed voices are wondering if now is the right time to pursue wholesale root and branch change which will be very distracting in our largest and most expensive public service? Managers fashioning lifeboats for themselves may have concerns other than achieving efficiency savings.

Cromwellian thoroughness and speed

The reforms to commissioning and accountability aim to be Cromwellian in thoroughness and speed.  Andrew Lansley seems to be taking Tony Blair’s approach further and faster than anyone thought possible, but the difference is there seems to be a map this time.  Our modern day “major generals” (aka Strategic Health Authorities)  are being marched off to the Tower awaiting termination  - or as Mr Lansley termed it “disempowerment of bureaucracies” – by 2012, to be followed by PCTs by April 2013.

As we move towards then, will the crowd be shouting “behold the heads of tyrants” as we breath the free and pure air of GP commissioning, or will we just be too distracted to care?  And will there be anyone left in PCT land by then to turn off the lights, cancel the milk and put the cat out?

Not just valuable but vital

Only to be dismissed at once when at a recent training we did for Wandsworth NHS we met active and interested older volunteers who were a strong reminder of the value of this resource. As people often tasked to set up user panels as well as train them,  we readily acknowledge that many a participative venture would collapse without the time, energy and ideas that the older involved and retired citizen brings to the table. Is the prospect of working beyond the current pensionable age  a threat to this resource? We say no so long as we get the flexibility in the labour market that encourages part-time working. The new volunteer in this context would have a wider set of choices between paid and unpaid work which may well enhance the chances of their participation and at the same time increase the value of that contribution because they remain connected to the wider world through their paid work.

Eight New Laws of LINks

Certainly when we look at any form of future development for LINks, no progress would be possible without good quality people being ready and able to serve on and contribute to them. The elder community will remain an important pool of recruits. Andrew was very gung ho about LINks in his piece. He wrote that LINks must not only survive but take on a more robust role. To that end, he promulgates eight news laws for LINks – essential reading for policy makers we would say.

Reorganisation – flavour of the month

Reorganisation – how fast, how far, how good – crops up in almost everyone  of our blogs. Caroline Millar writes 12 years as a parent have provided many an example of how change gets sneaked through in the summer. Leading the charge for change in education, is the new Secretary of State for Education. Glinting in the sunshine of his new powers like the granite of his native Aberdeen, Mr Gove is granite-hard in his resolve to create Academies asap. In doing so he seems very ready to dump any commitment to consultation in his rush to deliver. He is of course ready to consult later when all the important stuff has got done. Why are citizens cynical about consultation do I hear you ask?

Trust the Teachers and GPs

Having identified  bureaucracy as the enemy of local change, local authorities in education and PCTs in health are being bypassed in favour of teacher and doctor power. Parents are also being urged to get involved in schools but the knowledge that entry to ‘their’ school will probably be by lottery  so their own children may not get in, is a bit of a bummer. However as graduates of the consumer movement in a number of its manifestations, three MAC partners have a superstitious reverence for the power of Young and so cannot dismiss entirely the chances of success for y0ung Young channelling his dad’s influence from beyond the grave to create a new school in West London. (It is an article of faith for all consumerists and others in the field of social policy generally that  ‘Michael Young later Lord Young of Dartington was the greatest British social entrepreneur of the second half of the 20th century’. Discuss using one side of the paper only).

GPs working within consortia are going to be the new commissioners of health and social care services. We have two immediate concerns. The first is the very uneven record of GPs in setting up effective and credible patient participation bodies. Secondly, our work with commissioners of long term and not so long term neurological conditions makes us very wary about GPs being able to take on this complex and often neglected area of clinical and social care practice. Andrew discusses his reservations in a head to head with Lynn Young of the RCN here.

More substantively, his piece Neuro Knees Up or Knockback? raises important questions on how best the Third Sector and in particular neurological organisations can safeguard what we know is a considerable investment in making the best of the commissioning system in place now. Reform threatens to waste this effort and set back their work in improving care for people with neurological conditions.